Provider Demographics
NPI:1689652497
Name:LYCOMING PHYSICAL THERAPY
Entity Type:Organization
Organization Name:LYCOMING PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURGER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:570-368-8389
Mailing Address - Street 1:1009 BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754
Mailing Address - Country:US
Mailing Address - Phone:570-368-8389
Mailing Address - Fax:570-368-8391
Practice Address - Street 1:1009 BROAD STREET
Practice Address - Street 2:
Practice Address - City:MONTOURSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17754
Practice Address - Country:US
Practice Address - Phone:570-368-8389
Practice Address - Fax:570-368-8391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PALY627781Medicare PIN
PA1013120001Medicare NSC